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For Better Population Health, Invest in Primary Care Providers

Population health improves when communities add more primary care providers, but the looming shortage of PCPs may curtail these clinical gains.

February 26, 2019 - A higher number of primary care providers (PCPs) in a given region is associated with significant gains in life expectancy for resident populations, according to a new study published in JAMA Internal Medicine.

Adding just 10 PCPs per 100,000 individuals was associated with a 51.5-day increase in life expectancy across the population, with significant reductions in mortality related to common chronic diseases such as cardiovascular disease, cancer, and respiratory conditions.

With an extra 10 PCPs per 100,000, deaths from cardiovascular disease decreased by 30.4 deaths per million; cancer mortality dropped by 23.6 deaths per million; and respiratory mortality by 8.8 deaths per million.

The study, conducted by researchers from top institutions including Stanford University, Harvard, and UNC Chapel Hill, reconfirms the prevailing wisdom that primary care providers are critical for the prevention and management of chronic conditions.

“The largest decreases in cause-specific mortality associated with increased primary care physician density were for cardiovascular disease, cancer, and respiratory tract disease, conditions with strong evidence of amenability to primary care management or with delayed mortality conditional on early screening through primary care,” the study stated.

However, the uneven distribution of PCPs between urban and rural areas, as well as a steady overall decline in new physicians choosing to enter primary care, are putting stress on populations that do not have adequate access to fundamental services.

“Although the total number of primary care physicians has increased in the United States, owing to disproportionate rural losses and general population size increases, the distribution of US primary care physicians per 100,000 population has changed, leading to a net loss in mean primary care physician supply at the county level,” the study explained.

“The mean density of primary care physicians relative to population size decreased from 46.6 per 100,000 population to 41.4 per 100,000 population, with greater losses in rural areas.”

The Association of American Medical Colleges (AAMC) predicts that the nation may be facing a shortage of close to 50,000 PCPs by 2030, contributing to an overall shortfall of physician talent that could have dire implications for an aging, growing population.

The researchers note that dramatic disparities in compensation between primary care and specialty care are luring physicians away from the general practice environment, leading to a problematic shortage of PCPs.

A recent survey from Medscape found a 45 percent differential in compensation between PCPs and specialists, equating to nearly $100,000 a year in “lost” revenue for PCPs.

While the shortage of PCPs is leading to a modest increase in salary for those who stay in the primary care environment, the wage gap may simply be too wide for physicians to feel comfortable leaving so much money on the table.

The healthcare industry is deploying a number of different strategies to help close gaps in primary care access for patients.

One popular tactic is the use of team-based care, which leverages advanced practice practitioners (APPs) such as nurse practitioners (NPs) and physician assistants (PAs) to provide routine services and expand availability.

The JAMA Internal Medicine study was not able to examine the impact of nurse practitioners or physician assistants on population health due to inconsistencies in the data used for the model.

But other data from the industry indicates that NPs and PAs can indeed have a positive impact on access to chronic disease management, preventive care, and routine services.

The American Association of Nurse Practitioners (AANP) notes that the number of NPs is at an all time high, with close to 248,000 licensed professionals currently in practice.

Unlike physicians, the vast majority of NPs and physician assistants choose to practice in the primary care environment, added a separate study from UnitedHealth Group (UHG). Seventy-eight percent of APPs work in primary care compared to just one-third of physicians, the 2018 data revealed.

By 2025, the number of NPs in the primary care environment is expected to increase by 47 percent, UHG said, and PAs are anticipated to increase by 38 percent.

As a result, these professionals may help reduce the shortage of primary care providers by 70 percent.

However, physicians will always play a vital role in the primary care environment, and APPs cannot close all of the gaps produced by the dearth of MDs.

A growing number of medical schools are currently taking the lead in encouraging new graduates to enter primary care, and are working to address the financial aspects of doing so.

NYU and Kaiser Permanente are both launching brand new medical schools with free tuition. Both organizations will promote a population health approach to care – the new NYU Long Island School of Medicine is specifically designed to train primary care providers.

Helping students graduate without crushing debts may make it easier for new physicians to choose a slightly less lucrative career path in the primary care setting, the medical schools theorize.

However, it will likely take much broader investment in primary care to close the gulf for patients, the JAMA Internal Medicine researchers asserted.

“Policy initiatives, such as Medicare’s Accountable Care Organization programs, that attempt to focus on population health and spending and thereby rely on primary care physicians continue to gain traction, but these programs fail to explicitly direct more resources to primary care physician supply, instead relying on the usual Medicare fee schedule,” the study says.

“Other forms of investment, such as the National Health Services Corps, the Teaching Health Centers program, and Title VII programs, also offer the opportunity to increase the density of primary care physicians, especially in underserved areas.”

“Whether these initiatives will encourage more graduating medical students to enter primary care remains to be seen.”